Treatment of Sinusitis
The treatment of bacterial sinusitis includes amoxicillin-clavulanate (875/125 mg twice daily for 7-14 days) as first-line therapy, with adjunctive therapies such as intranasal corticosteroids and nasal saline irrigations to improve outcomes. 1
Diagnosis
Before initiating treatment, it's important to correctly identify bacterial sinusitis:
- Bacterial sinusitis is likely when symptoms persist beyond 10 days 1
- Diagnosis requires at least two major criteria:
- Unilateral or bilateral infraorbital pain
- Purulent rhinorrhea 1
- Coronal CT scan is the gold standard for diagnosis when imaging is needed 1
Antibiotic Treatment Algorithm
First-line therapy:
- Amoxicillin-clavulanate (875/125 mg twice daily for 7-14 days) 1
For penicillin allergies:
- Non-severe allergy: Doxycycline 1
- Severe allergy: Second or third-generation cephalosporins (cefuroxime axetil or cefpodoxime proxetil) 1, 2
Duration:
- Standard treatment: 7-10 days 1
- Short-course regimens with cefuroxime-axetil or cefpodoxime-proxetil have shown efficacy in just 5 days 1, 3
Important caveat: Not all sinusitis requires antibiotics. Viral sinusitis with mild symptoms of short duration should not be treated with antibiotics to avoid promoting resistance 1
Adjunctive Therapies
Intranasal Corticosteroids:
- Recommended as adjunctive therapy 1
- Fluticasone propionate nasal spray may provide relief starting from the first day of use 4
- Significantly reduces symptoms of acute sinusitis when added to antibiotics 5
- Particularly effective for inflammatory symptoms (headache, congestion, facial pain) 5
Symptomatic Relief:
- Analgesics and antipyretics for pain and fever 1
- Decongestants for temporary relief (limited evidence) 1
- Nasal saline irrigations to improve mucociliary clearance 1
When to Refer to a Specialist
Referral to an ENT specialist is recommended for:
- Recurrent sinusitis (2-3 episodes per year) despite appropriate treatment 1
- Sinusitis significantly affecting quality of life 1
- Severe sinus pain or thick nasal discharge not responding to treatment 4
Surgical Considerations
Consider surgical intervention when:
- Nasal polyps obstruct sinus drainage despite medical treatment 1
- Complications are threatened 1
- Chronic rhinosinusitis (symptoms >12 weeks) is refractory to medical treatment 1
- Anatomic abnormalities contribute to sinus obstruction 1
Special Considerations
- For children aged 4-11 using fluticasone propionate nasal spray, limit use to two months per year 4
- Monitor for potential side effects of intranasal corticosteroids, including minor nosebleeds, dry or irritated nose/throat 4
- Stop intranasal corticosteroids if exposed to chicken pox, measles, or tuberculosis 4